Provider Demographics
NPI:1750645529
Name:BERGQUIST, JOHN RANDOL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDOL
Last Name:BERGQUIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:BERGQUIST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1145 S UTICA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-3825
Mailing Address - Fax:
Practice Address - Street 1:1145 S UTICA AVE STE 701
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4019
Practice Address - Country:US
Practice Address - Phone:918-582-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56488208600000X
CAA160484208600000X
OK38503208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN020003475Medicare PIN